‘Doing death’ the Mediterranean way: end-of-life in a segregated nursing home

ABSTRACT

This paper presents ethnographic data on a migrant-specific nursing home ward in Switzerland. It shows that the structurally pre-defined segregation of residents sharing a common characteristic affects care practices along three dimensions: performances of sameness/otherness, informalisation of relationships and language/understanding. Yet, ‘death work’ showed little difference to non-segregated wards. However, relatives’ practices in dying trajectories were less congruent with nursing home ‘doing death’, and collisions may evolve. The need for negotiations associated with running a segregated ward seems to elicit enhanced institutional reflexivity with potential to increase the ability of institutions to provide diversity-sensitive services to all residents.

KEYWORDS:

• Nursing home
• end-of-life care
• doing death
• migration
• diversity
• ethnography

Disclosure statement

No potential conflict of interest was reported by the authors.

Notes

1. The data presented in this paper were collected within the framework of a larger research programme financed by the Swiss National Science Foundation (NRP 67 ‘End of Life’, grant number 406740_139365/1) aiming at a better understanding of end-of-life experiences, practices and service needs in Switzerland to inform future research and policies.

2. The notion of ‘doing death’ refers to Ethnomethodology and the idea that social realities are constructed in concrete practices and interactions, as for example elaborated in the work of West and Zimmerman (1991) on ‘doing gender’.

3. All institutions and persons have been assigned pseudonyms.

4. The vast majority of Swiss nursing homes are not-for-profit. All nursing homes (also the profit-oriented ones) offer standard nursing services reimbursed by health insurances and a set of residential and social services paid by the individual resident. Not-for-profit nursing homes get public financial support and are obliged to conceptualise their services so as not to exceed a defined amount secured by social welfare if individual residents are not in a position to pay for it by themselves. Nursing home care is guaranteed to everyone, including migrants holding a residence permit.

5. The term ‘guest-worker’ regime refers to a policy-driven migration pattern prevalent in Switzerland in the decades after World War II, focusing on short-term migration from Southern Europe for work purposes, usually aimed at flexible, low-paid workforce and based on short- to middle-term residence permits, conditional on being employed. Migrants were expected to return to their home countries, resulting in very low emphasis on integrative measures. Policy measures to foster return did, however, not succeed; along with circular migration patterns, a considerable part of the ‘guest-worker’ migrants stayed for decades, worked and had children, and is now retired or facing retirement. As a study by Bolzman, Fibbi, and Vial (2001) showed, a third each of Italian ‘guest-worker’ migrants facing retirement either plans to return upon retirement, to regularly commute or to stay with their children and grand-children. Swiss ‘guest-workers’ immigrated to a large extent from Italy, starting directly after World War II and going on until the 1970s, followed by other (smaller) groups from the Mediterraneans, for example from Portugal, Spain, former Yugoslavia and Turkey (see also Piguet, 2006; Soom Ammann, 2011).

6. Switzerland has a rapidly ageing population, with a current old age dependency ratio of 29 persons aged over 65 in relation to 100 persons of working age (20–64 years) (see population statistics for the year 2016 on www.bfs.admin.ch). Migration ratio is high: The permanent population with non-Swiss nationality amounts to 24.6 % (2015) of approx. 8.5 million inhabitants. If naturalised and second-generation migrants are included, the migrant population of Switzerland is estimated to a little more than one third (e.g. 36% in 2014, estimated on the basis of the working population with foreign-born parents, SAKE database, see www.bfs.admin.ch for details). The migrant population’s age structure is considerably younger: the old age dependency ratio of the non-Swiss population parts is 16, compared to the population parts with Swiss nationality displaying a ratio of 38 (BFS 2017: 23). Higher ages in the migrant population are, however, increasing among the larger national groups with long-term residencies from neighbouring countries, among which Italians are the largest group (and the only group characterised by mainly low-skilled work migration patterns). In 2014, there were a total of 164,137 Italian migrants aged 50+ permanently living in Switzerland, of which 66,588 persons were aged 70+ (population statistics, www.bfs.admin.ch).

7. Thus, staff requirements are situationally interpreted and expanded to include not only Italian, but also ‘Mediterranean’ or ‘Mediterranean-like’ characteristics, as will be illustrated later on.

8. Issues regarding double rooms and ‘doing death’ will be addressed elsewhere (Rauber et al., in preparation).

9. In this paper, we refer to an understanding of performance as elaborated in the frame of Ethnomethodology, especially by Goffman’s idea of everyday performances of self towards an audience (Goffman (1990 (1956)) constrained by principles of social order governing interactions and respective interpretations (Goffman, 1974).

10. The Brunnhof nursing home is a secularist institution in a predominantly protestant region.

11. These legitimacy discourses also inform the ways in which residents and relatives discursively refer to the Mediterranean wards. Those opting for such a ward mostly argue in favour of recognition of specific needs and previous neglect. On the other hand, some residents (and/or relatives) with Italian migrant background have explicitly chosen to be cared for on an integrated ward, to avoid the supposed ‘ghettoisation’ or the expected ways of ‘doing community’ on those wards.

12. This explicit physical exchange of signs of affection was mainly observed between female caregivers and residents.

13. The issue of family orientation of migrants is debated, specifically with respect to care. While there is a tendency in research and practice to assign family orientation to ‘culture’ and ‘primary socialisation’, that is to pre-migration contexts, migrant experiences and experiences with welfare systems are additional dimensions to be considered in this context (see e.g. Soom Ammann, 2011). Informalisation is not necessarily a primordial cultural trait, but also seems to be a promising strategy to deal with precarities and insecurities related to migration (see e.g. Môret & Dahinden, 2009 for the Swiss context). For this reason, it may be an organisational pattern very commonly observed in migrant communities, irrespective of origin and host country. Family and other forms of informal communities based on long-term reciprocity (such as associations, peer groups, patron/client groups) may be more helpful in times of dependency and insecurity than formal welfare state-based modes of relationship (see also Rauber et al., in preparation).

14. Care work is one of the domains of the labour market in Switzerland most easily accessible to migrants whose professional qualification is not valued by Swiss employers, and due to this, the workforce in nursing homes is—not only, but especially at the level of low-skilled work (nursing aides)—extremely heterogeneous. Language fluency is one of the main problems associated with this situation.

15. Although Swiss legislation as well as Palliative Care policies strongly advocate advance care directives, the resident populations of Brunnhof and Centre Burgallee mostly had not filled out written patient directives, or only in a very minimal form, e.g. stating that they did not wish ‘to be put on tubes’, as several residents and staff members called it, and designating a proxy.

Additional information

Funding

This work was supported by the Swiss National Science Foundation [406740_139365/1]

Notes on contributors

Eva Soom Ammann

Eva Soom Ammann, PhD, is a social anthropologist whose principal research interests are concerned with migration and health, with a specific focus on ageing, diversities and inequalities. Dying and death in old age is one of her current research topics. She is a lecturer and senior researcher in nursing studies at the Bern University of Applied Sciences, and an associate researcher at the Institute of Social Anthropology, University of Bern, in Switzerland.

Gabriela Rauber

Gabriela Rauber, MA, is a social anthropologist and PhD student. Her research interests are death and dying, end-of-life practices, EOLD and exchange relationships. Her current focus lies on the significance of informality in end-of-life care in Swiss nursing homes. She is doing her PhD at the Institute of Social Anthropology, University of Bern and also works as a research assistant at the University Centre for Palliative Care, Inselspital, Bern University Hospital.

Corina Salis Gross

Corina Salis Gross, PhD, is Head of the “Diversity and Equity” Research Unit at the Swiss Institute for Public Health and Addiction, University of Zurich, and an associate researcher at the Institute of Social Anthropology, University of Bern, in Switzerland. Her main research areas are death and dying, old age, migration, addiction, and public health.